Evaluation of Transmyocardial Laser Revascularization by Following Objective Parameters of Perfusion and Ventricular Function[1]

Background: Does transmyocardial laser revascularization (TMLR), a new surgical technique for treating patients with otherwise intractable angina pectoris, improve myocardial perfusion, metabolism, and, consequently, function? Methods: Patients referred for TMLR, alone or with coronary artery bypass grafting (CABG), were preoperatively evaluated clinically and by treadmill stress testing, echocardiography, ventriculography, radionuclide assessment of perfusion and metabolism, and hemodynamic assessment. Intraoperatively it was decided that some patients only required CABG. Follow-up evaluations were repeated after 6 (n = 40) and 12 months (n = 23) and compared with preoperative values. Results: CABG only was performed in 35 cases, TMLR + CABG in 17, TMLR only in 45. 1-year mortality was 11 % in the TMLR, zero in the TMLR + CABG, and 11 % in the CABG groups. In all groups a significantly improved CCS angina- and NYHA class was observed immediately after operation and after 6 and 12 months. In all study groups treadmill tolerance (p < 0.05) improved, but regional and global function, perfusion at rest, and metabolism were not significantly changed at 6 and 12-months follow-ups. Perfusion studies under stress demonstrated an improvement only in the CABG group after 12 months (p < 0.05), whereas in both TMLR groups the lasered ischemic segments remained unchanged. Conclusions: TMLR significantly improves long-term clinical status and treadmill stress tolerance, but appears to have little if any effect upon regional and global function, perfusion, and metabolism.

Key words:

Transmyocardial laser revascularization - Coronary disease - Ischemia - Revascularization - Myocardium

1 This paper was presented in part at the 28^th Annual Meeting of the German Society for Thoracic and Cardiovascular Surgery, Dresden, February 1999

References

• 1 Mirhoseini M, Shelgikar S, Cayton M M. New concepts in revascularization of the myocardium.  Ann Thorac Surg.. 1988;  45 415-20
• 2 Frazier O H, Kadipasaoglu K A, Cooley D A. Transmyocardial laser revascularization. Does it have a role in the treatment of ischemic heart disease?.  Tex Heart Inst J.. 1998;  25 24-9
• 3 March R J. Transmyocardial laser revascularization with CO₂ laser: one year results of a randomized, controlled trial.  Sem Thorac Cardiovasc Surg.. 1999;  11 12-8
• 4 Horvath K A, Cohn L H, Cooley D A. et al . Transmyocardial laser revascularization: results of a multicenter trial with transmyocardial laser revascularization used as sole therapy for end-stage coronary artery disease.  J Thorac Cardiovasc Surg.. 1997;  113 645-54
• 5 Cooley D A, Frazier O H, Kadipasaoglu K A. et al . Transmyocardial laser revascularization: clinical experience with 12-month follow-up.  J Thorac Cardiovasc Surg.. 1996;  111 791-9
• 6 Lutter G, Frey M, Saurbier B. et al . Treatment option for patients with otherwise intractable angina pectoris: transmyocardial laser revascularization.  Z Kardiol.. 1998;  87 (Suppl. 2) 199-202
• 7 Schofield P M, Sharples L D, Caine N. et al . Transmyocardial laser revascularization in patients with refractory angina: a randomised controlled trial.  Lancet.. 1999;  353 519-24
• 8 Naegele H, Stubbe H M, Nienaber C, Rödiger W. Results of transmyocardial laser revascularization in non-revascularizable coronary artery disease after 3 years follow-up.  Eur Heart J.. 1998;  19 1525-30
• 9 Lutter G, Yoshitake M, Takahashi N. et al . Transmyocardial laser-revascularization: experimental studies on prolonged acute regional ischemia.  Eur J Cardio-thorac Surg.. 1998;  13 694-701
• 10 Lutter G, Schwarzkopf J, Takahashi N, Yoshitake M, Nitzsche E, Martin J, Beyersdorf F. Transmyocardial laser revascularization: experimental studies in healthy porcine myocardium.  Ann Thorac Surg.. 1999;  67 1708-13
• 11 Lutter G, Martin J, Köster F. et al . Analysis of the new indirect revascularization method by determining objective parameters of clinical chemistry, histo-chemistry and histology.  Eur J Cardio-thorac Surg.. 1999;  15 709-16
• 12 Lutter G, Saurbier B, Nitzsche E. et al . Transmyocardial laser revascularization (TMLR) in patients with unstable angina and low ejection fraction.  Eur J Cardio-thorac Surg.. 1998;  13 21-6
• 13 Lucignani G, Paolini G, Landoni C. et al . Presurgical identification of hibernating myocardium by combined use of technetium-99m hexakis 2-methoxyisobutylisonitrile single photon emission tomography and fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography in patients with coronary artery disease.  Eur J Nucl Med.. 1992;  19 874-81
• 14 Di Carli M, Sherman T, Khanna S. et al . Myocardial viability in asynergic regions subtended by occluded coronary arteries: relation to the status of collateral flow in patients with chronic coronary artery disease.  J Am Coll Cardiol.. 1994;  23 860-8
• 15 Braunwald E. Unstable Angina. A classification.  Circulation.. 1989;  80 410-14
• 16 Schiller N B, Shah P M, Crawford M. et al . Recommendations for quantitation of the left ventricle by two-dimensional echocardiography.  J Am Soc Echocardiography.. 1989;  2 358-67
• 17 Sheehan F H, Bolson E L, Dodge H T, Mathey D G, Schofer J, Woo H W. Advantages and applications of the centerline method for characterizing regional ventricular function.  Circulation.. 1986;  74 293-305
• 18 Frazier O H, Cooley D A, Kadipasaoglu K A. et al . Myocardial revascularization with laser - preliminary findings.  Circulation.. 1995;  92 (Suppl. II) II58-II65
• 19 Rimoldi O, Burns S M, Rosen S D, Wistow E, Schofield P M, Camici P G. Measurements of myocardial blood flow with positron emission tomography before and after transmyocardial revascularization (abstract).  Circulation.. 1998;  98 (Suppl. I) I407
• 20 Moosdorf R. Transmyocardial laser revascularization.  Z Kardiol.. 1997;  86 115-24
• 21 Jones R H, Kesler K, Phillips III H R. et al . Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease.  J Thorac Cardiovasc Surg.. 1996;  111 1013-25
• 22 Lutter G, Schwarzkopf J, Lutz C, Martin J, Beyersdorf F. Histologic findings of transmyocardial laser channels after two hours.  Ann Thorac Surg.. 1998;  65 1437-9
• 23 Mirhoseini M, Shelgikar S, Cayton M M. New concepts in revascularization of the myocardium.  Ann Thorac Surg.. 1988;  45 415-20
• 24 Fleischer K J, Goldschmidt-Clermont P J, Fonger J D, Hutchins G M, Hruban R H, Baumgartner W A. One-month histologic response of transmyocardial laser channels with molecular intervention.  Ann Thorac Surg.. 1996;  62 1051-8
• 25 Hardy R I, James F W, Millard R W, Kaplan S. Regional myocardial blood flow and cardiac mechanics in dog hearts with CO₂ laser-induced intramyocardial revascularization.  Basic Res Cardiol.. 1990;  85 179-97
• 26 Fisher P E, Khomoto T, DeRosa C M, Spotnitz H M, Smith C R, Burkhoff D. Histologic analysis of transmyocardial channels: Comparison of CO₂ and Holmium:YAG lasers.  Ann Thorac Surg.. 1997;  64 466-72
• 27 Mack C A, Magovern C J, Hahn R T, Sanborn T, Lanning L, Ko W, Isom O W, Rosengart T K. Channel patency and neovascularization after transmyocardial revascularization using an eximer laser.  Circulation.. 1997;  96 (Suppl. II) II65-II69
• 28 Horvath K A, Greene R, Belkind N, Kane B, McPherson D D, Fullerton D A. Left ventricular functional improvement alter transmyocardial laser revascularization.  Ann Thorac Surg.. 1998;  66 721-5
• 29 Kwong K F, Kanellopoulos G K, Nickols J C, Pogwidz S M, Saffitz J E, Schuessler R B, Sundt III T M. Transmyocardial laser treatment denervates canine myocardium.  J Thorac Cardiovasc Surg.. 1997;  114 883-90
• 30 Al-Sheikh T, Allen K B, Straka S P. et al . Cardiac sympathetic denervation after transmyocardial laser revascularization.  Circulation.. 1999;  100 135-40
• 31 Arora R C, Thompson G W, Hirsch G M. Transmyocardial laser revascularization does not denervate the heart.  Circulation.. 1998;  17 (Suppl. I) I541

1 This paper was presented in part at the 28^th Annual Meeting of the German Society for Thoracic and Cardiovascular Surgery, Dresden, February 1999